11/5/2014

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How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis? The Hospitalist

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How to Manage Pain in Patients with Renal

Insufficiency or End-Stage Renal Disease on
Dialysis?
August 1, 2013 Ruchika Harisingani, MD, Maha Saad, PharmD, CGP, BCPS, Manouchkathe Cassagnol, PharmD, CGP,
BCPS, Long Island Jewish Medical Center, New Hyde Park, N.Y.
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A 70-year-old male with ESRD on hemodialysis presents with methicillinresistant Staphylococcus aureus (MRSA) bacteremia and ankle pain after
a fall. An MRI of his ankle is negative, and he is started on acetaminophen
and lidocaine patches, which result in adequate pain relief of the ankle.
He later develops significant neuropathic pain in both arms, and a CT
scan of the cervical spine reveals a cervical abscess and osteomyelitis. The
patient desires pain relief but adamantly refuses narcotics, stating: I
dont want to get addicted. How can his pain be managed?

Overview

Pain is a common problem in patients with renal insufficiency and endstage renal disease (ESRD) and can have a significant effect on the
patients quality of life.1 When assessing a patients pain, assess both the
severity of the pain (such as on an analogue scale, 0-10) and the
characteristics of the pain. Pain is most commonly characterized as
Explore this issue:
nociceptive, neuropathic, or both. Nociceptive pain can be further
August 2013
classified as arising from either somatic or visceral sources, and is often
described as dull, throbbing, cramping, and/or pressurelike.1 Neuropathic
pain is often described as tingling, numbing, burning, and/or stabbing.
Accelerated Diagnostic
Protocol for Chest Pain
Results in Earlier Discharge
of Low-Risk Patients

http://www.the-hospitalist.org/article/how-to-manage-pain-in-patients-with-renal-insufficiency-or-end-stage-renal-disease-on-dialysis/

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11/5/2014

How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis? The Hospitalist

When assessing pain, assess both the

severity of the pain (such as on an analogue
scale, 0-10) and the characteristics of the
pain. Pain is most commonly characterized
as nociceptive, neuropathic, or both.

Key Points
Safe nonopioid options for pain
management in renally impaired and
dialysis patients include acetaminophen
and certain NSAIDs, such as ibuprofen.
Fentanyl, hydrocodone, and
hydromorphone are the safest opioids
to use in renally impaired and dialysis
patients.
Tramadol in lower doses may also be
safely used in renally impaired and
dialysis patients.
Low-dose gabapentin and lidocaine
patches can be safely used as adjunctive
therapy in renally impaired and dialysis
patients; TCAs may also be used in
lower doses in renally impaired
patients.

Additional Reading
Mid-Atlantic Renal Coalition and the
Kidney End-of-Life Coalition. Clinical
algorithm & preferred medications to
treat pain in dialysis patients. Coalition
for Supportive Care of Kidney Patients
website. Available at:
http://www.kidneysupportivecare.org/PhysiciansClinicians/PainSymptomManagement.aspx. Accessed June 30,
http://www.the-hospitalist.org/article/how-to-manage-pain-in-patients-with-renal-insufficiency-or-end-stage-renal-disease-on-dialysis/

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11/5/2014

How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis? The Hospitalist

2013.
Launay-Vacher V, Karie S, Fau JB,
Izzedine H, Deray G. Treatment of pain
in patients with renal insufficiency: the
World Health Organization three-step
ladder adapted. J Pain. 2005;6(3):137148.
Dean, M. Opioids in renal failure and
dialysis patients. J Pain Symptom
Manage. 2004;28(5):497-504.
Arnold R, Verrico P, Davison SN.
Opioid use in renal failure. Medical
College of Wisconsin website. Available
at:
http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_161.htm.
Accessed June 30, 2013.

Pages: 1

Filed Under: Clinical, Key Clinical Questions, Patient Care

Tagged With: dialysis, disease, management, narcotic, opioid, outcomes, pain, renal, treatment
Issue: August 2013

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Manage Sickle Cell Pain

Crises

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Liver Disease (MELD)
May Help Determine
Mortality Risk

Are Stress-Dose
Steroids Indicated in
Patients with Adrenal
Insufficiency
Hospitalized with
Noncritical,
Nonsurgical Illness?

Accelerated Diagnostic
Protocol for Chest Pain
Results in Earlier
Discharge of Low-Risk
Patients

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